MEDICARE: DR. MELVIN E. JACKSON O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	0618000174	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	040971	OTHER	VA	BC/BS
3	54-1390819	OTHER	VA	TRICARE

General Provider Information

NPI Number	:	1588657217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MELVIN E. JACKSON O.D.

Provider Business Mailing Address
First Line	:	4642 HAYGOOD RD
Second Line	:	SUITE 1
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23455-5436
Country	:	US
Telephone Number	:	757-464-5842
Fax Number	:	757-464-4745

Provider Business Practice Location Address
First Line	:	4642 HAYGOOD RD
Second Line	:	SUITE 1
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23455-5436
Country	:	US
Telephone Number	:	757-464-5842
Fax Number	:	757-464-4745

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2005
Last Update Date	:	11/07/2008

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